Lakhisarai (Bihar) and Bengaluru: On March 24, 2020, Ramgarh police station received a phone call from the village of Durdih in Lakhisarai district in southern Bihar, 140 km from the state’s capital, Patna. The person on the line said that someone had come from the “city” and had “coronavirus”, said Dhirendra Kumar Pathak, the police station in-charge. The police reached the house at around 8 p.m., but there was no one there, Pathak said. A member of the family told the police that the person, their son-in-law, had already left.

Such calls have been frequent in recent days, Pathak said, ever since a government-imposed 21-day lockdown led to an exodus of migrants from large cities back to their home towns and villages. Several incidents where migrants are not being allowed to enter their villages or being handed over to the police have been reported from Patna, Rajasthan and West Bengal.

The stigma associated with being a COVID-19 patient could hinder those with symptoms from reaching out for help, experts told IndiaSpend. Some migrants could be unknowing carriers of COVID-19 and spread the infection, as not all districts are equipped to screen and quarantine them.

Public healthcare systems in the migrants’ home state are under-equipped to deal with the challenge of COVID-19, and experts warn that many of the migrants might well be infected and take the pandemic with them, as IndiaSpend reported on March 28, 2020.

Ostracism

People have been calling up hospitals, the police stations and district government officials to report COVID-19-related issues. In most cases, an ambulance accompanies the police officer or government official. “When we reach the spot, it is usually a case of travel from other districts or states… We try to tell them not to panic and explain the symptoms of the disease,” Pathak said.

In Durdih, the family of the returnee are continuing to face ostracism even after his departure, the father-in-law told IndiaSpend, requesting not to be named. They had food stored at home but were “not being allowed to take water from the local hand pump”, he said. After some social workers and villagers intervened, the family are now being “allowed” to fetch water from the animals’ water source.

Pathak said the family has not reported this ostracism to the police.

Bihar’s first case of a COVID-19 death, a contagious viral respiratory disease, was of a person from Munger, the region where Lakhisarai district is located, according to media reports. The person died at the All India Institute for Medical Sciences in Patna.

The World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020. In India, it had infected 1,397 and killed 35, as of 8:30 pm on March 31, 2020, when data were last released by the Ministry of Health and Family Welfare, according to Coronavirus Monitor, a HealthCheck database. Bihar had 15 cases and one death.

An estimated 2.2 million from Bihar migrate to other states, according to data from the 2001 census. Some of them work in Kerala (which now has 234 COVID-19 cases), Delhi (97 cases), Rajasthan (74 cases) and Maharashtra (216 cases). Many migrate overseas, often to the Middle East.

‘Outsiders not allowed’

In many villages around Lakhisarai district, inhabitants and local leaders have barricaded the entry and exit points of villages, and placed posters that say: ‘Outsiders are not allowed’, asking those who return to self-report. If they do not self-report, other villagers report them to the authorities, residents told IndiaSpend.

The fear that outsiders will bring COVID-19 is rampant across villages.

A makeshift barricade at the entrance of a village in Lakhisarai district with a poster that reads: ‘Outsiders not allowed’, March 25, 2020.

“Most villagers think that anyone who has come from outside is a coronavirus patient,” said Ravi Ranjan, the block development officer at Dhamdaha in Purnea district, in northern Bihar. Even if workers who have travelled from afar have a mild cough or are sneezing, people panic and report them as cases of coronavirus on our helpline, he said. “The teams have been running around day and night due to this. Since the last two to three days, we are appealing to people to fight with the disease but not distort the social fabric of the villages,” said Ranjan.

“The stigma around COVID-19 is not specific to rural areas and even cities and urban areas are witnessing this,” said Soumitra Pathare, a consulting psychiatrist and director of the Centre for Mental Health Law and Policy in Pune. “If you have more stigma, the people are more afraid to come out and seek help or treatment,” he said, giving the example of stigma around the Human Immunodeficiency Virus (HIV) which causes the Acquired Immunodeficiency Syndrome (AIDS) in some patients.

The problem is not community surveillance but a lack of understanding of the disease as well as of community surveillance, experts told IndiaSpend. It means different things to different people--doctors, police and the common man, said Pathare. “ Surveillance is not vigilantism but maybe that is how it has got through,” he added.

“Our authorities have relied on this notion of fear to get everybody to act but the danger of that is it results in stigma,” he said, adding that “ensuring the information flow, open communication and dealing with misconceptions is what is required” as most people do not understand what the disease is.

Screening, tracking, quarantining

Not all districts in Bihar are adequately prepared to handle the return of these migrants. Although some have facilities for quarantining and door-to-door visits by healthcare workers, others are unable to track and screen migrants or quarantine them properly, our investigation found.

More than 400,000 people had been screened at transit points and over 21,000 at airports and 221 passengers had completed the 14-day quarantine, as of March 30, 2020, according to the State Health Society of Bihar, under the National Health Mission. The data do not clarify whether this includes migrants returning from other Indian states.

About 2,570 ‘passengers’ were under observation in various districts as of March 30, 2020, data show. Most (648) were in Siwan, a district in northwestern Bihar.

Vigilantism by villagers is partly an outcome of inadequate awareness and partly a lack of comprehensive government screening of returning migrants, our investigation showed.

In some cases, returnees are mingling freely with their families, never having been tested for symptoms.

Villagers do not know what quarantine means and there is no mechanism to ensure that they quarantine themselves, said a Patna-based social activist, working with an international organisation on climate change in Bihar, requesting anonymity. “Issuing instructions on paper does not work in our kind of setup,” he said. “Returning workers are both scared and careless and do not want to go and stay in government buildings.”

The Bihar government issued a circular on March 22, 2020, instructing district magistrates to make temporary arrangements in government schools and community centres to quarantine returning workers. The government has sanctioned Rs 100 crore from the chief minister’s relief fund for food and other arrangements at such locations, according to this statement by the Bihar government.

“Nobody is staying in our facility as of now but we have enough space,” said Lakhisarai block development officer Pushpa Lakda, when IndiaSpend spoke to her on March 28, 2020. She said schools have been prepared for quarantining of the returning migrants, water is available as most schools have a hand pump, but food will have to be brought by their families. “Each school has two to three rooms and all the people coming back from such places will be kept together so we can handle a large number of people,” she said.

In Siwan district, the local administration is focusing on the 648 people who are under observation and on international migrant workers, said Amit Kumar Pandey, the district magistrate. When asked about the measures the administration is taking, he said he had no details since the sub-divisional magistrate was in-charge.

Siwan had its first COVID-19 case on March 26, 2020, when a person returning from Dubai tested positive, according to Ashesh Kumar, the civil surgeon at Sadar Hospital in Siwan.

Home quarantine, door-to-door visits

Some districts are doing better than others in handling returnees.

In Sheohar district, in northern Bihar, the administration decided that they would quarantine migrants at home since getting the schools and community centres ready at short notice seemed impossible, said Rakesh Singh, a social activist from the area, who was part of the meetings with local leaders.

The district has counted 563 migrants so far who have come back, said Avaneesh Kumar Singh, the district magistrate. A pamphlet has been put outside their homes to indicate they are under quarantine but many are hiding details of their travel history, he said. The medical team now goes door-to-door, responds to phone calls and makes sure that no one with symptoms comes to the health centre, he said.

Someone who has symptoms should not go to the health centre but call the helpline and a medical team will visit them at home, officials said.

Lack of public health, testing facilities

Overall, Bihar’s health infrastructure is poor. It ranked 20 of 21 states on the Niti Aayog’s Health Index report published in June 2019. For its 120 million population, it currently has four operational COVID-19 test centres, three in Patna and one in Darbhanga, according to Coronavirus Monitor.

By March 30, 2020, the state had tested 869 samples, of which 15 were found positive, data show.

Hospitals have been asked to increase the number of beds and set up isolation wards, but many do not have the capacity to expand.

Siwan has a 110-bed hospital and the government has ordered that six isolation wards be created for potential COVID-19 cases, said Kumar, the civil surgeon at Siwan’s Sadar Hospital. “But just creating only a ward does not help… there is a lack of space, manpower and the medical supply is very limited,” he said, citing the example of the expansion of the hospital from 30 beds some time ago without a corresponding increase in other medical facilities as a futile step.

The hospital is also facing a shortage of protective equipment for health workers. “We have to offer everything to the team in the field since they are examining the patients,” Kumar said. “So, I do not have enough for the other staff or myself.”

For other districts, such as Gopalganj, well-equipped hospitals are few and far between.

For any serious treatment, people in Gopalganj rely on Baba Raghav Das Medical College in Gorakhpur, (120 km west) or the government hospitals in Patna (150 km southeast), said Nand Kishore, the civil surgeon at the Sadar hospital in Gopalganj. “I am meeting the district magistrate to see what system can be put in place,” he said. “The tests are being done in Patna but in case of a crisis, the ambulances will be allowed to go to Gorakhpur.” Special permission is needed as the central government has ordered that state borders be closed during the lockdown.

Protective gear for grassroots workers

The government has said that grassroot health workers such as accredited social health activists (ASHAs) will conduct door-to-door campaigns to educate people about the need to identify high risk cases and quarantine them.

But unlike in Siwan, not all districts are able to provide protective gear to their health workers.

“We have not been given any masks or gloves or anything to protect ourselves when we go out and visit families where people have returned from other areas,” said Anita Devi, an ASHA worker with the Ramgarh primary health centre (PHC) in Lakhisarai. “How are we supposed to go and meet people without any protection?”

Asha Devi said she had heard about a person who had come from outside the district with flu-like symptoms. “We do not know what happened to him or where he was taken,” she said, highlighting the lack of information on what happens when someone is detected with symptoms similar to that of COVID-19. Such incidents made her fearful of going out in the field without protective equipment, she said.

The Ramgarh PHC team is ready to handle cases, said Kanchan Kumar, who is in-charge there, but “we are also receiving many unnecessary calls”. “We were given eight kits with masks and gowns to test such patients and they have almost all been used up. We are trying to do whatever we can, but the resources are limited.”

IndiaSpend reached out to officials of Bihar’s health ministry, including principal secretary Sanjay Kumar, by phone multiple times on March 30 and March 31, 2020 and emailed Bihar’s health department. We also called Arvinder Singh, the special secretary, Manoj Kumar, additional secretary of the State Health Society, and Lokesh Kumar Singh, secretary of the Swasthya Suraksha Samiti. This story will be updated when we receive a response.

(Agrawal is an independent journalist. Kumar Neeraj, founder-director of Khetee, an agroforestry nonprofit, contributed to this story from Lakhisarai district.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Parul Agrawal